Hepatic encephalopathy after transjugular intrahepatic portosystemic shunt

Riggio, Oliviero; Merlli, M; Pedretti, Giorgio; Servi, Ronald J.; Meddi, Patrizia; Lionetti, Raffaella; Rossi, Plinio; Bezzi, Mario; Salvatori, Filippo Maria; Ugolotti, U; Fiaccadori, F; Capocaccia, L.

doi:10.1007/bf02282344

Cited by 145 publications

(127 citation statements)

References 14 publications

Supporting

Mentioning

119

Contrasting

Unclassified

Order By: Relevance

“…The morbidity rates noted herein were comparable with established figures, confirming the relatively high risk of hepatic encephalopathy following TIPS creation (19,20). Unfortunately, final PSG levels that may improve medically refractory ascites also increase the risk of hepatic encephalopathy (21,22).…”

Section: Discussionsupporting

confidence: 81%

“…Unfortunately, final PSG levels that may improve medically refractory ascites also increase the risk of hepatic encephalopathy (21,22). Although we found no independent predictors of hepatic encephalopathy, it should be noted that nearly all instances of hepatic encephalopathy were mild cases, graded at 0 or 1, which are generally treatable with dietary modification and medical therapy (23)(24)(25).…”

Section: Discussionmentioning

confidence: 75%

See 1 more Smart Citation

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

View full text Add to dashboard Cite

ORIGINAL ARTICLE PURPOSE This study was performed to assess the safety, efficacy, and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) creation for treatment of medically refractory ascites and to identify prognostic factors for clinical response, morbidity, and mortality. MATERIALS AND METHODSIn this retrospective study, 80 patients (male:female, 52:28; mean age, 56 years; mean Model for End-Stage Liver Disease [MELD] score, 15.1) who underwent elective TIPS creation for refractory ascites between 1999-2012 were studied. A medical record review was performed to identify data on demographics, liver disease, procedures, and outcome. The influence of these parameters on 30-day, 90-day, and oneyear mortality was assessed using binary logistic regression. Overall survival was analyzed with Kaplan-Meier statistics. RESULTS TIPS was successfully created using covered (n=70) or bare metal (n=10) stents. Hemodynamic success was achieved in all cases. The mean final portosystemic pressure gradient (PSG) was 6.8 mmHg. Thirty-day complications included mild encephalopathy in 35% of patients. Clinical improvement in ascites occurred in 78% of patients, with complete resolution or a ≥50% decrease in 66% of patients. No predictors of response or optimal PSG threshold were identified. The 30-day, 90-day, and one-year mortality rates were 14%, 23%, and 33%, respectively. Patient age (P = 0.026) was associated with 30-day mortality, while final PSG was associated with 90-day (P = 0.020) and one year (P = 0.032) mortality. No predictors of overall survival were identified. CONCLUSION TIPS creation effectively treats medically refractory ascites with nearly 80% efficacy. The incidence of mild encephalopathy is nontrivial. Older age and final PSG are associated with mortality, and these factors should be considered in patient selection and procedure performance.T he development of medically refractory ascites is associated with a grave prognosis in patients with liver cirrhosis. One-year survival in this population is less than 50%, and there is an increased risk of complications such as spontaneous bacterial peritonitis, hepatorenal syndrome, and dilutional hyponatremia (1). Moreover, these patients typically have low Model for End-Stage Liver Disease (MELD) scores despite their high mortality rate, and thus hold low positions on national transplant listings (2, 3). Transjugular intrahepatic portosystemic shunt (TIPS) creation, an established treatment for complications of portal hypertension, has demonstrated utility in patients with refractory ascites (4). By diverting blood from the portal venous system to the systemic circulation, TIPS acts to lower hepatic sinusoidal pressure and increase effective circulatory flow, thereby reducing excess sodium retention and achieving ascites recurrence rates as low as 30% (5). Two recent studies revealed reduced mortality in patients undergoing TIPS placement, compared with those receiving serial large-volume paracentesis procedures, with one-year survival rates ra...

show abstract

Section: Discussionsupporting

confidence: 81%

Section: Discussionmentioning

confidence: 75%

Transjugular intrahepatic portosystemic shunt for the treatment of medically refractory ascites

Parvinian¹,

Bui²,

Knuttinen³

et al. 2013

Diagn Interv Radiol

View full text Add to dashboard Cite

show abstract

“…Too little shunting might not sufficiently decrease portal pressure to prevent rebleeding, while too much shunting might cause HE. 17,18 Although the risk of rebleeding was considerably reduced *In this group, two patients underwent TIPS because of rebleeding, and developed 3 episodes of encephalopathy included in the total count. One patient underwent surgical porta-caval anastomosis because of rebleeding and developed an unknown number of episodes of hepatic encephalopathy (only one included in the total count).…”

Section: Discussionmentioning

confidence: 93%

Transjugular intrahepatic portosystemic shunt versus endoscopic sclerotherapy for the prevention of variceal bleeding in cirrhosis: A randomized multicenter trial

et al. 1998

View full text Add to dashboard Cite

Transjugular intrahepatic portosystemic shunt (TIPS), a new technique for the treatment of portal hypertension, has been successful in preliminary studies to treat acute variceal hemorrhage and to prevent variceal rebleeding. The purpose of this multicenter, randomized controlled trial is to compare the efficacy of TIPS with that of endoscopic sclerotherapy in the prevention of variceal rebleeding in cirrhosis. Eighty-one cirrhotic patients, with endoscopically proven variceal bleeding, were randomized to either TIPS (38 patients) or endoscopic sclerotherapy (43 patients). Randomization was stratified according to the following: if bleeding occurred F 1 week (stratum I); if bleeding occurred 1 to 6 weeks (stratum II); and if bleeding occurred 6 weeks to 6 months (stratum III) before enrollment. Follow-up included clinical, biochemical, Doppler Ultrasound, and endoscopic examinations every 6 months. During a mean follow-up of 17.7 months, 51% of the patients treated with sclerotherapy and 24% of those treated with TIPS rebled (P ‫؍‬ .011). Mortality was 19% in sclerotherapy patients and 24% in TIPS patients (P ‫؍‬ .50). Hepatic encephalopathy (HE) developed in 26% and 55%, respectively (P ‫؍‬ .006). A separate analysis of the three strata showed that TIPS was significantly more effective than sclerotherapy (P ‫؍‬ .026) in preventing rebleeding only in stratum I patients. TIPS is significantly better than sclerotherapy in preventing rebleeding only when it is performed shortly after a variceal bleed; however, TIPS does not improve survival and is associated with a significantly higher incidence of HE. The overall performance of TIPS does not seem to justify the adoption of this technique as a first-choice treatment to prevent rebleeding from esophageal varices in cirrhotic patients. (HEPATOLOGY 1998; 27:40-45.)Cirrhotic patients who survive an episode of bleeding from esophageal varices have an extremely high risk of rebleeding. 1 For this reason, several treatment modalities aimed at preventing variceal rebleeding have been tested by means of randomized controlled trials. 2 So far, pharmacological therapy with betablockers and endoscopic injection sclerotherapy are the most widely used treatments. 3 Nevertheless, both treatments are not fully satisfactory, as the average rebleeding rate with each therapy is about 48%. 2 Recently, a new angiographic technique, i.e., the transjugular intrahepatic portosystemic shunt (TIPS) has been proposed to treat portal hypertension. 4 This procedure creates a communication between the hepatic and the portal vein within the liver, thus decompressing portal hypertension. 5 Patency of the shunt is maintained by an expandable metal stent. Currently, TIPS has been successfully used in the following: in acute variceal hemorrhage uncontrolled by medical and endoscopic treatment 6,7 ; in preventing rebleeding in patients in whom sclerotherapy failed 5 ; in refractory ascites 8 ; in the Budd-Chiari Syndrome 9 ; and in patients who bleed while awaiting liver transplantation. 10 However, ...

show abstract

“…We discovered that the THF measured one week after TIPS was more than that of before TIPS, while FHF was reduced significantly in all subjects. It may be considered that the reduction of portal vein pressure and increase in portosystemic shunting caused by TIPS are associated with the reduction of hepatic perfusion, which can partly explain the high incidence of hepatic encephalopathy in patients with liver cirrhosis [24][25][26] .…”

Section: Discussionmentioning

confidence: 99%